setmelanotide acetate — Blue Cross Blue Shield of Montana

Initial criteria

• The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: another FDA labeled indication for the requested agent and route of administration OR another indication supported in compendia for the requested agent and route OR prescriber has submitted two peer-reviewed journal articles supporting proposed use as generally safe and effective (randomized, double blind, placebo controlled trials acceptable; case studies not acceptable)

Approval duration

12 months